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Type 2 diabetes usually affects middle-aged and older people, but increasing numbers of younger people are also at risk.
Some communities are affected disproportionately, with people of South Asian and Black ethnicity being between two and four times more likely to develop type 2 diabetes than those of white ethnicity.
“Type 2 diabetes is a growing problem,” says Emma McManus, a research fellow at the University of Manchester. “It is a leading cause of sight loss and a major contributor to a range of conditions, including kidney failure, heart attack and stroke. However, if you change your lifestyle, the risk of developing type 2 diabetes reduces.”
The NHS Diabetes Prevention Programme, run by NHS England in partnership with Diabetes UK, is offered to adults in England who are at a high risk of developing type 2 diabetes. Over 1.2 million people have been offered support on the programme since it was first launched in 2016.
University of Manchester (UoM) research published in February revealed that patients taking part in the programme reduced their risk of developing type 2 diabetes by one fifth. The researchers suggest that weight loss is the most likely cause for the risk reduction. This follows another UoM study published in March 2022 that showed the programme had resulted in a seven per cent reduction in the number of new type 2 diabetes diagnoses in England between 2018 and 2019.
“Type 2 diabetes is essentially a lifestyle condition that, in most cases, can be fully reversed with lifestyle changes,” says Eoghan O’Brien at Bannside Pharmacy in Portglenone, Northern Ireland. “But the patients need to keep making these lifestyle changes – if they go back to the same foods, inactivity and stress, for example, their type 2 diabetes is most likely to return. Even with the best medical interventions, microvascular and macrovascular complications will continue to deteriorate, so it’s important to address the root cause.”
Diabetes care involves an individualised approach to manage blood sugars effectively, taking into account patients’ needs, wishes and concerns. Management may require a combination of medication and lifestyle changes, but many people are able to manage their condition with lifestyle changes only.
Samina Ali, advanced practice pharmacist in NHS Greater Glasgow and Clyde with a special interest in diabetes, runs a regular diabetes clinic, offering oral therapies (such as metformin), insulin and GLP-1 analogues (such as semaglutide). “Some people refuse to go on medication and ask for ‘another three months’ to see if they can get to target, while others want to go down that route from the beginning,” she says.
“The medication route and choice often depend on the patient’s age. We may try a more aggressive medical approach with younger people and try lifestyle changes for three months in older people before considering medication. But if they already have a high HbA1c, we may suggest metformin. It’s important to make sure people aren’t being over-medicated by taking medicines that aren’t working – and to switch them onto something else if necessary.”
Mr O’Brien says conversations within the pharmacy may help open up discussions about lifestyle management. “It’s always better to help someone who asks for help, as community pharmacists can only work with customers who are motivated and focused,” he says. “Some people may start taking metformin but say that they don’t want to take medicines, while others may be put on insulin but say that they don’t like needles.”
“Type 2 diabetes is essentially a lifestyle condition that, in most cases, can be fully reversed with lifestyle changes”
Lifestyle approaches
Research shows that weight management can put type 2 diabetes into remission for two years or more and reduce, or eliminate, the need for medicines. According to NICE guidance,updated in June 2022, people with type 2 diabetes should be offered dietary advice with a personalised diabetes management plan, including other aspects of lifestyle modification such as increasing physical activity and losing weight. If they are overweight, they should be encouraged to lose an initial five to 10 per cent of their total body weight. Smoking cessation advice, controlling alcohol intake and blood pressure control are also important.
“Lifestyle changes go hand in hand with medication, so it’s important to find out what people are already doing,” says Ms Ali. “Rather than simply telling them what they should be doing, give them ideas of how to do it, or do more of it, such as going for a walk each day to fit in with their usual routine.
“I explain the basics of a healthy diet, as many people don’t understand how to control their blood sugars. Some people will be looking at sugar content of food, rather than carbohydrate content, and need to understand how to read food labels. We have seen patients who make more changes to their diet and exercise go into remission.”
Mr O’Brien says it takes time for a community pharmacist to coach patients through a lifestyle-based service. “We often need to have a conversation about hidden sugars – this isn’t only about a spoonful of sugar in a cup of tea,” he says. “Ideally, patients need to cut out carbs, as even wholemeal bread and brown rice (better choices for other people) can still spike blood sugars. Patients need to replace grains with something else that they enjoy eating. If they are switching to foods they don’t enjoy, they won’t maintain these changes.”
Ade Williams, superintendent pharmacist at Bedminster Pharmacy in Bristol, says it’s important to educate pharmacy customers about weight management and other lifestyle changes without coming across as patronising.
“For many people, being newly diagnosed can be a big shock and leave them with a sense of failure, thinking ‘there’s nothing more I can do’,” he says. “It’s important to make sure they aren’t being left to their own devices and that they don’t lose hope. Provide printed information from the NHS and Diabetes UK and make sure people are aware of the resources and support available locally. Signpost them to social prescribing and language support, if required, as well.”
Technology approaches
For some people with type 2 diabetes, technology is an important part of their day-to-day management. This may be in the form of insulin pumps and smart insulin pens, glucose monitors, and/or apps to help with recording glucose readings and managing weight loss, exercise and carb counting.
With flash glucose monitors (Freestyle Libre) and continuous glucose monitors, patients can check their blood glucose levels without the need to prick their fingers. They wear a small sensor on their body, day and night – they can then see fluctuations in their blood glucose levels on their mobile phone, or another device, and understand how food, activity and other factors have an impact on their blood glucose control. They can set an alarm to sound if their glucose levels go too low or too high, so that they can take the appropriate action.
“The Freestyle Libre is a very useful tool,” says Mr O’Brien. “Someone may be aware that they will have a blood sugar spike if they eat a biscuit or drink a can of Coke, but by using the Freestyle Libre, they can actually see this happening over a period of 24 hours.
According to NICE guidelines, if someone with type 2 diabetes lives in England and Wales and uses insulin two or more times a day, they should be offered Freestyle Libre if they have recurrent or severe hypoglycaemia; have impaired hypoglycaemia awareness; can’t monitor their own blood sugar levels due to a condition or disability, but can use a scanning device (or someone can do this for them); or they would otherwise be advised to do a finger prick test at least eight times a day.
In Scotland, the local health boards have mixed criteria, but national guidelines recommend that people who manage type 2 diabetes with multiple (usually four or five) daily injections or insulin pump therapy should have access to flash glucose monitoring. “In Scotland, the eligibility and criteria for the Freestyle Libre are different to those in England and Wales,” says Ms Ali. “Certain people with type 2 diabetes on insulin will get the device prescribed, and also some people who aren’t checking their blood glucose levels often enough.”
If people don’t qualify for a flash glucose monitor or continuous glucose monitor on the NHS, they can self-fund a device, if they are financially able to do so, by buying it directly from the manufacturer or through some pharmacies and shops. They may also be able to arrange a free 14-day trial.
Ozempic hits the headlines
Last month, the National Institute for Health and Care Excellence (NICE) issued guidance on the use of injectable semaglutide (also known as Wegovy and made by Novo Nordisk) as an option for weight management in adults, when prescribed alongside a reduced-calorie diet and an increase in physical activity.
NICE first recommended using semaglutide for weight loss in draft guidance last year. The medicine is already licensed in the UK and available on the NHS for managing blood glucose levels in people with type 2 diabetes, under the brand names Ozempic (injections) and Rybelsus (tablets).
Under the new NICE guidance for weight loss, semaglutide injections must be prescribed by a doctor – they can be used for a maximum of two years and only within a specialist multidisciplinary NHS weight management service. The injections will be prescribed to eligible adults with a body mass index (BMI) of at least 30.0kg/m2 (obesity) or a BMI of around 27 kg/m2 to 30 mg/kg2 (overweight) in the presence of at least one weight-related comorbidity.
Although Wegovy isn’t yet available in the UK for weight management, some high street pharmacies, such as Boots, already have sections on their websites where the public can sign up to show interest for a private doctor-run weight loss service using weekly Wegovy injections. In the USA, many celebrities have labelled Wegovy as a “wonder drug” for weight loss, and rising public awareness has led to supply issues of Ozempic injections for diabetes, both here and abroad.
There are concerns that making semaglutide available for weight loss could lead to further shortages for patients with diabetes, and using the medication may mean that the underlying causes of obesity are not being addressed.
Community pharmacist Ade Williams says there is also some confusion among diabetes patients now that semaglutide is being marketed for weight loss as well.
“Community pharmacists play an important role in offering support and guidance,” he says, “and can use the New Medicines Service to make sure patients understand their diabetes medicines and diagnosis.
“It’s important to take a proactive approach, as type 2 diabetes management isn’t just about medication – look at diet, activity levels, motivation and issues around self-esteem, along with lifestyle choices and health inequalities.”
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